Application for. Professional Corporate Licensure. to Practice Engineering and/or Land Surveying. in North Carolina. under the provisions of

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1 Application for Professional Corporate Licensure to Practice ineering and/or Land Surveying in North Carolina under the provisions of NC G.S. 55B THE PROFESSIONAL CORPORATION ACT ABCDEFGH Application Fee: $ THE NORTH CAROLINA BOARD OF EXAMINERS FOR ENGINEERS AND SURVEYORS 4601 Six Forks Road, Suite 310 Raleigh, North Carolina (919) (August 11) Board Use Only Fee: Approved:

2 Credit Card Information Sheet Accepted Credit Cards: Visa, MasterCard, Discover To pay the Application Fee by credit card, the following information must be provided: Amount charged will be: $ (Application Fee) Check Card Type: Visa MasterCard Discover Credit Card Number: Exact Name as it as it appears on Card: Card Expiration Date (enter Mo/Yr): Typed Name of Cardholder: Signature of Cardholder: Cardholder acknowledges receipt of goods and/or services in the amount of the total shown hereon and agrees to perform the obligations set forth in the Cardholder s Agreement with the issuer.

3 APPLICATION INSTRUCTIONS GENERAL All Applications must be complete and returned with the original signature to the Board office. The non-refundable $ application fee is payable by check, money order or credit card (Visa, MasterCard, Discover). Checks or Money Orders should be made payable to the NC Board of Examiners. If paying by Credit Card, applicant must submit the attached Credit Card Information Sheet. APPLICATION 1. Applicants must complete the entire application form. Incomplete applications will not be processed and will be returned to the applicant. Sections A & B must account for 100% of the corporate stock. Please include the application cover page. 2. If licensee in Section A is not a NC licensee then provide one state of licensure and corresponding license number where they are a licensed engineer, land surveyor or other service in good standing that will also be authorized in North Carolina. The state listed must be one where the firm is also authorized to practice that service. 3. Each office in Section C that will offer engineering and/or land surveying services must list a NC licensee for that profession (engineering and/or land surveying only) and their corresponding license number. Licensees for in-state offices must comply with the Resident requirement in NCAC Title 21, Chapter 56 (Board Rules), Section.0901(c). All out-of-state locations must designate one licensee (for each profession offered) who will be in responsible charge of services from that location. 4. An Officer of the corporation and licensed North Carolina ineer or Land Surveyor must sign the certificate and have it notarized. 5. If applying as a Domestic Professional Corporation, In addition to the Professional Corporate Application, submit a copy of the proposed Articles of Incorporation (NC Secretary of State Form PC-05) with the Professional Corporate Licensure Application. 6. If applying as a Foreign Professional Corporation, in addition to the Professional Corporate Application, submit a copy of the proposed Application for Certificate of Authority (NC Secretary of State Form PC-01), a copy of existing corporate Articles of Incorporation and any amendments to present, a copy of a Certificate of Good Standing/Existence less then (6) months old from the state where the corporation was originally incorporated. 7. Upon approval of the application, a Certificate for Filing and additional instructions will be forwarded to the applicant, for use in support of the filing of the Articles of Incorporation, Certificate of Authority, or amendments to existing documents with the North Carolina Department of the Secretary of State. No documents may be filed with the Secretary of State until approval is received by this office. 8. If the Corporation is applying to offer additional professional services as listed under G.S. 55B-14 (Architecture, Landscape Architecture, Soil Science and/or Geology), a separate application will need to be submitted to the appropriate licensing board(s) in North Carolina. 9. Subsequent to the Secretary of State filing, THE CORPORATION MUST FORWARD A COPY OF THE RECORDED DOCUMENTS RETURNED TO THEM TO THE BOARD OF EXAMINERS TO COMPLETE THE LICENSURE PROCESS. The documents may be mailed, faxed (919) , or ed to the Director of Business Licensure (firms@ncbels.org). ANNUAL RENEWAL 1. Certificates of Licensure of Professional Corporations under Chapter 55B of the North Carolina Statutes expire in accordance with the provisions of 55B-11 and 21 NCAC (b) and are required to be renewed yearly. 2. Upon written application of the Corporation, accompanied by the appropriate renewal fee, the licensing Board shall renew the Certificate of Licensure of a Professional Corporation as required by statute, providing the Board finds that the Corporation has complied with all regulations and the provisions of G. S. 55B. 3. If the Corporation does not apply for Renewal of its Certificate of Licensure within thirty (30) days after the date of the expiration of such Certificate, the Certificate of Licensure shall be automatically suspended with the Secretary of State. The Certificate may be reinstated within the calendar year upon the payment of the required renewal fee plus a reinstatement fee, if such Corporation is then otherwise qualified and entitled to renewal of its Certificate of Licensure. 4. Failure of a Corporation to renew its License for a period of one (1) year shall require the Corporation to submit a new application and meet all requirements in effect for Licensure. 5. Renewal reminders will be mailed to Licensees in good standing one month before expiration. Upon submitting the appropriate renewal documents to the Board Office, a Certificate of Renewal will be sent to the Corporation.

4 Type or Print Name of Corporation (or proposed name of Corporation) CERTIFICATE 1. Ownership of shares of said Corporation will be as required by 55B-4(2) and 55B-6 of the General Statutes listed herein. 2. All Professional ineers and Professional Land Surveyors providing professional services in North Carolina are duly licensed or are working under the responsible charge of a dul y licensed North Carolina Professional ineer or Professional Land Surveyor. 3. Only persons holding a N orth Carolina professional license will have authority to control the engineering or land surveying product, or to determine the clientele or project selection process of the North Carolina Professional Corporation. 4. No disciplinary action is pending against any of the persons listed by any jurisdiction. 5. The North Carolina Professional Corporation will render only professional services as approved by the licensing board(s). 6. All offices in North Carolina will be s taffed by a r esident professional(s), duly licensed to practice the professional services authorized for the corporation in North Carolina. 7. The North Carolina Professional Corporation will fully comply with Board Rule.0702, the Rules of Conduct of Advertising, in any and all brochures, correspondence, listings or other public communications. 8. The Corporation will be operated in full compliance with the requirements of the Professional Corporation Act, as well as the regulations of the North Carolina Board of Examiners. The Board of Examiners will be promptly notified of any change in personnel status. AFFIDAVIT AND NOTARIZATION The undersigned certifies that he or she is (or upon i ncorporation, will be) an Officer, Director and Shareholder of the above Professional Corporation, and is currently licensed with the North Carolina Board of Examiners for ineers and Surveyors. Further, this application is (or will be) duly authorized by the Board of Directors of said corporation, and that the statements made in said application are true and accurate. Signature Name (Typed) NC Professional License No. Federal Tax ID Number Sworn to and subscribed before me this day of, 20 Notary Public My Commission expires

5 OFFICERS, DIRECTORS, SHAREHOLDERS, PROFESSIONAL EMPLOYEES, AND NON-LICENSED SHAREHOLDER EMPLOYEES OF: Name of Corporation Mailing Address Physical (street) Address (if different than mailing) () ( ) Telephone Fax of Primary Contact for Company A. List Professional Personnel who have stock ownership and are licensed to practice in North Carolina** or another jurisdiction (only the stock of licensees in the professions authorized in NC can be counted): Name (Indicate by an X the status of each person, as applicable) Exact Percent Profession, License No. & of stock Employee State Officer** Director** owned ** At least one North Carolina PE or P must be an Officer, Director (Board of Directors) and shareholder of the Professional Corporation for EACH profession the company wishes to offer ( 55B-4; 55B-14) B. List all other Shareholding employees of the corporation (this includes licensees in Professions that are not authorized in North Carolina. All non-licensed shareholders must be employees): Name Address Officer (If App.) Director (If App.) Exact Percent of stock owned Employee (Total shares owned by those listed in Section B may not exceed 1/3) Stock owned by non-licensees % C. Offices of the Professional Corporation: Main Office Address Check Service(s) Offered List Resident NC licensee for profession(s) offered at each in-state office and/or the NC licensee in responsible charge of each out-ofstate location. Resident PE/P must comply with NCAC Title 21, Chapter 56, Board Rule.0901(C). Individuals NC License. No. Office 1 Office 2 Office 3 For sections A, B, and C, attach additional sheets as necessary.